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Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure a physician caring for a patient in active labor and the delivery of a newborn in the facility's emergency department (ED) was credentialed to perform this service for one of one medical record reviewed (MR30); the facility failed to establish policies and procedures for the care and treatment of patients in labor; the facility failed to establish policies and procedures for the mixing and administration of medications used during and after labor; and, the facility failed to establish policies and procedures addressing the requirements for documenting the progress of labor for one of one medical record reviewed (MR30) .

Findings include:

1) Review on September 30, 2015, of the facility's "Medical Staff Bylaws," approved September 24, 2014, revealed "... Article 5: Procedures for Appointment and Reappointment 5.1 General Procedure The Staff, with the assistance of Administration, through its designated Services shall investigate and consider each application for appointment or reappointment to the Staff and each request for modification of Staff membership status and shall adopt and transmit recommendations thereof to the Board. ... 5.4-4 Service Action Each Service in which the applicant seeks privileges shall review the application, the supporting documentation, and such other information available to it that may be relevant to consideration of the applicant's qualifications for the Staff category, Service affiliation, clinical privileges to be granted, and any special conditions to be attached to the appointment. The reason for each recommendation shall be stated and supported by reference to the completed application and all other documentation considered by the Service, all of which shall be transmitted with the report. Any minority view shall also be reduced to writing, supported by reasons and references, and transmitted with the majority report. ... Article 6: Privileges 6.1 Exercise of Privileges Every practitioner providing direct clinical services at the Hospital by virtue of Staff membership or otherwise shall, in connection with such practice and except as provided in Section 6.5, be entitled to exercise only those clinical privileges or provide patient care services as are specifically granted pursuant to the provisions of these Bylaws and the Staff Rules and Regulations. ... 6.5 Emergency Privileges For the purpose of this Section, an "emergency" is defined as a condition in which serious or permanent harm would result to a patient, or in which the life or a patient is in immediate danger and any delay in administering treatment would add to that danger. In the case of an emergency, any practitioner, to the degree permitted by license, regardless of Service, Staff status, or clinical privileges, shall be permitted to do, and shall be assisted by Hospital personnel in doing, everything possible to save the life of a patient or to save a patient from serious harm. A practitioner utilizing emergency privileges shall provide to the Medical Executive Committee in writing a statement explaining the circumstances giving rise to the emergency."

Review on September 30, 2015, of CF15's Service of Medicine - Specialty of Family Practice Delineation of Hospital Privileges revealed this physician requested the following privileges on January 19, 2012: "Medicine Lumbar puncture, Cardiopulmonary resuscitation, Advanced life support (with respirator) - temporary only for stabilization with internal medicine consultant, Cardiac Monitored Bed admitting with Internal Consultation, Pediatric Procedures, Uncomplicated newborn care, ENT [Ears Nose and Throat] Surgery Treatment of minor abrasions and lacerations, General Surgery I (Incision) [and] D (Drainage), Excision of lesions of skin and its appendages, Repair of superficial wounds, Thoracentesis and paracentesis, Urology Urethral catheterization, circumcision - infant, Orthopedic Surgery Arthrocentesis and Joint Injections, Gynecologic Surgery I [and] D, Endometrial biopsy (aspiration technique only), biopsy and/or excision of superficial lesions, and Colposcopy." The Hospital Administrator approved CF15's privileges on February 9, 2012, and the Chief of Staff and Chief of Service approved CF15's privileges on February 27, 2012. Further review of CF15's Service of Medicine - Specialty of Family Practice Delineation of Hospital Privileges revealed no documentation this physician requested privileges to care for a mother in labor.

Review on September 30, 2015, of CF1's Service of Emergency Medicine Delineation of Hospital Privileges revealed this physician requested "... Emergency Medicine Privileges: ... Genitourinary Techniques Foley Catheters, Suprapubic catheterization, Precipitous delivery of newborn, Culdocentesis ..."

Review of MR30 on September 30, 2015, revealed this patient presented to the facility's Emergency Department (ED) on February 7, 2014, in active labor. Further review revealed CF15 delivered MR30's baby and placenta, placed the baby on MR30's abdomen, collected cord samples and performed continuous fundus massage.

Interview with EMP3 on September 30, 2015, at approximately 11:00 AM confirmed CF15 delivered MR30's baby and placenta, placed the baby on MR30's abdomen, collected cord samples and performed continuous fundus massage while MR30 was a patient in the ED. Further interview with EMP3 revealed the ED staff called the family practice clinic and requested CF15 to come to the facility's ED to care for MR30 while in labor and to deliver this patient's baby. EMP3 revealed MR30's delivery was not life threatening.

Interview with EMP4 on September 30, 2015, at approximately 12:00 PM revealed CF1 was credentialed by the facility to care for a patient in labor and the delivery and care for a newborn. Further interview with EMP4 revealed CF15 was not credentialed by the facility to care for a patient in labor and deliver and care for a newborn.

2) A request was made of EMP3 on September 30, 2015, for facility policies, procedures and / or guidelines for Emergency Department (ED) staff to follow regarding patients presenting to the ED in labor. No policies, procedures or guidelines were provided.

Interview with EMP3 on September 30, 2015, at approximately 11:45 AM confirmed the facility had no policies, procedures and / or guidelines for ED staff to follow regarding patients presenting to the ED in labor.

3) A request was made of EMP3 on September 30, 2015, for facility policies, procedures and / or guidelines for ED staff to follow regarding the mixing and administration of medications used for a patient in labor. No policies, procedure or guidelines were provided.

Interview with EMP3 on September 30, 2015, at approximately 11:45 AM confirmed the facility had no policies, procedures and / or guidelines for ED staff to follow regarding the mixing and administration of medications used for a patient in labor.

Review of MR30 on September 30, 2015, revealed CF15 ordered Oxytocin (Pitocin - a medication used to induce labor and / or control bleeding after childbirth) 10 units / ml (milliliter) 30 units Intravenous (IV) Continuous infusion for MR30 on February 7, 2014. Further review revealed nursing documentation dated February 7, 2014, at 9:40 AM indicating nursing started the Oxytocin wide open following the delivery of MR30's baby.

Interview with EMP3 on September 30, 2015, at approximately 11:50 AM revealed facility staff mixed MR30's Pitocin 10 units in a 500 millimeter bag of normal saline.

Interview with EMP3 on September 30, 2015, at approximately 11:50 AM confirmed CF15's order to ED nursing staff was to mix Oxytocin 30 units in a 500 milliliter IV solution of normal saline and to administer by a continuous drip. EMP3 confirmed CF15's order to mix 30 units of Oxytocin in a 500 milliliter bag of normal saline was not followed. EMP3 confirmed CF15's order to administer MR30's Oxytocin by continuous infusion was not followed.

4) A request was made of EMP3 on September 30, 2015, for facility policies, procedures and / or guidelines for ED staff to follow regarding documentation of the progress of labor in the medical record for a patient in labor. No policies, procedures or guidelines were provided.

Interview with EMP3 on September 30, 2015, at approximately 11:50 AM confirmed the facility had no policies, procedures and / or guidelines for ED staff to follow regarding documentation of the progress of labor in the medical record for a patient in labor.

Review of MR30 on September 30, 2015, revealed this patient presented to the ED on February 7, 2014, at 8:07 AM experiencing labor contractions and gave birth at 9:33 AM on February 7, 2014. Further review revealed no documentation of each time MR30 had a labor contraction; no documentation of the number of contraction this patient had while in labor or the fetal heart rate after each contraction. Continued review revealed no documentation on the time the placenta was delivered or when the cord was cut.

Interview with EMP3 on September 30, 2015, at approximately 11:55 AM confirmed MR30 presented to the ED on February 7, 2014, at 8:07 AM experiencing labor contractions and gave birth at 9:33 AM; there was no documentation of each time MR30 had a labor contraction; no documentation of the number of contraction this patient had while in labor or the fetal heart rate after each contraction and no documentation on the time the placenta was delivered or when the cord was cut.

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to follow its established policy for evaluating and re-evaluating a patient's pain level regarding pain medication administration for three of five medical record reviewed (MR8, MR18 and MR22).

Findings include:

Review on September 30, 2015, of the facility's "Pain Management" policy, last reviewed June 30, 2015, revealed "Policy: All admitted patients would be assessed for pain initially with admission assessment, and then subsequently thereafter according to assessment findings. Patients should receive treatment for pain relief as warranted and be monitored for effectiveness. Procedure: A. Assessment: ... pain assessment parameters should include location, intensity, duration, description, interventions provided, and response to interventions. ... 6. Pain intensity will be determined by the use of a pain-rating scale appropriate for the patients [sic] stage of growth and development and cognitive ability / 0 - 10 scale ... 10. In general, effectiveness of PRN [as needed] pain medications and other interventions should occur within 30 - 90 minutes after administration, or when therapeutic effectiveness can be assessed. ... B. Pain Scales: 1. Adult / Pediatric No Pain 0 Mild Pain 1 - 3 Moderate Pain 3 - 5 Severe Pain 5 - 7 Very Severe Pain 7 - 9 Worst Possible Pain 10 ..."

Review of MR8 on September 30, 2015, revealed this patient was admitted to the facility on September 28, 2015, for evaluation and treatment of cellulitis. Further review revealed the physician wrote an order instructing nursing staff to administer Dilaudid (a narcotic pain medication) 0.5 mg (milligrams) IV (intravenously) every 2 hours. Nursing staff administered the Dilaudid on September 29, 2015, at 7:57 PM for a pain rating of 5, at 9:48 PM for a pain rating of 6, and at 11:47 PM for a pain rating of 6. There was no documentation nursing staff assessed the effectiveness of the Dilaudid following the administration.

Interview with EMP2 on September 30, 2015, at approximately 8:45 AM confirmed MR8 was admitted to the facility for evaluation and treatment of cellulitis; the physician wrote an order instructing nursing staff to administer Dilaudid 0.5 mg IV every 2 hours; nursing staff administered Dilaudid on September 29, 2015, at 7:57 PM for a pain rating of 5; at 9:48 PM for a pain rating of 6, and at 11:47 PM for a pain rating of 6; and there was no documentation nursing staff assessed the effectiveness of the Dilaudid following the administration.

Review of MR18 on September 30, 2015, revealed this patient was admitted to the facility on September 28, 2015, for evaluation and treatment of abdominal pain. The physician wrote an order instructing nursing staff to administer Dilaudid 2 mg IV every 4 hours PRN [as needed] for moderate pain of 4 to 6 and severe pain 7 to 10. Nursing staff administered Dilaudid on September 30, 2015, at 1:33 AM and at 5:09 AM. There was no documentation nursing staff assessed the patient's pain level prior to administering the Dilaudid.

Interview with EMP2 on September 30, 2015, at approximately 9:00 AM confirmed MR18 was admitted to the facility for evaluation and treatment of abdominal pain; the physician wrote an order instructing nursing staff to administer Dilaudid 2 mg IV every 4 hours PRN for moderate pain of 4 to 6 and severe pain 7 to 10; nursing staff administered Dilaudid on September 30, 2015, at 1:33 AM and at 5:09 AM; and there was no documentation nursing staff assessed MR18's pain level prior to administering the Dilaudid.

Review of MR22 on September 30, 2015, revealed this patient was admitted to the facility on September 27, 2015, for evaluation and treatment of abdominal pain. The physician wrote an order instructing nursing staff to administer Dilaudid 2 mg IV every 2 hours PRN for moderate pain of 4 to 6 and severe pain 7 to 10. Nursing staff administered Dilaudid on September 28, 2015, at 10:53 AM. There was no documentation nursing staff assessed MR22's pain level prior to administering the Dilaudid. Nursing staff administered Dilaudid on September 30, 2015, for a pain rating of 8. There was no documentation nursing staff assessed the effectiveness of the Dilaudid following the administration.

Interview with EMP2 on September 30, 2015, at approximately 9:15 AM confirmed MR22 was admitted to the facility for evaluation and treatment of abdominal pain; the physician wrote an order instructing nursing staff to administer Dilaudid 2 mg IV every 2 hours PRN for moderate pain of 4 to 6 and severe pain 7 to 10; nursing staff administered Dilaudid on September 28, 2015, at 10:53 AM; and there was no documentation nursing staff assessed MR22's pain level prior to administering this Dilaudid. EMP2 confirmed nursing staff administered Dilaudid on September 30, 2015, for a pain rating of 8, and there was no documentation nursing staff assessed the effectiveness of the Dilaudid following the administration.

Based on review of facility documents, medical records (MR) and employee interview (EMP), it was determined the facility failed to complete the authorization for treatment and/or admission consent form for nine of 11 medical records reviewed (MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16 and MR40).

Findings include:

Review of the facility-provided "General Authorization for Treatment and/or Admission, Patient Business Services, Policy #RPH [Robert Packer Hospital]-D-920-107", last review date unknown, revealed "Policy: General authorization for the facility to provide treatment, submit claims and permit assignment of benefits. Registration clerks shall obtain the signature of the patient or the patient's authorized representative when appropriate. Procedure: The following form is required during registration interview. ..."

Interview on September 29, 2015, at approximately 2:00 PM, with EMP5 and EMP6, confirmed Troy Community Hospital did not have a specific policy to address the General Authorization for Treatment and/or Admission. EMP5 and EMP6 stated Troy Community Hospital followed the Robert Packer Hospital system wide policy above.

Review of the facility's "Authorization For Treatment And/Or Admission" form, no review date, revealed "... The undersigned certifies that he or she had read the foregoing and accepts the same: ..." This was followed by a place for the Patient's signature, the Agent's signature, the Date, the Time, and the Hospital/Clinic Representative Signature.

The following medical records were reviewed on September 29, 2015, at approximately 2:00 PM:

Review of MR12 revealed The Authorization for Treatment and/or Admission form had no documentation of the time on September 15, 2015, for the Physical/Occupational/Speech Therapy Outpatient Service.

Review of MR13 revealed the Authorization for Treatment and/or Admission form had no documentation of the time on September 14, 2015, for the Physical/Occupational/Speech Therapy Outpatient Service.

Review of MR14 revealed the Authorization for Treatment and/or Admission form had no documentation of the time on September 1, 2015, for the Physical/Occupational/Speech Therapy Outpatient Service.

Review of MR15 revealed the Authorization for Treatment and/or Admission form had no documentation of the time on June 18 and July 2, 2015, for the Physical/Occupational/Speech Therapy Outpatient Service.

Review of MR16 revealed the Authorization for Treatment and/or Admission form had no documentation of the time on July 21, 2015, for the Physical/Occupational/Speech Therapy Outpatient Service.

Interview on September 29, 2015, at approximately 2:00 PM, with EMP5 and EMP6, confirmed the Authorization for Treatment and/or Admission forms for MR12, MR13, MR14, MR15, and MR16 were incomplete. The time was not documented. EMP5 and EMP6 confirmed the Authorization for Treatment and/or Admission form was completed before the patient was seen for the Physical/Occupational/Speech Therapy Outpatient Service.

The following medical records were reviewed on September 30, 2015, at approximately 11:30 AM:

Review of MR9 revealed the Authorization for Treatment and/or Admission form had no documentation of the time on September 14, 2015, for the Respiratory Treatment Service.

Review of MR10 revealed the Authorization for Treatment and/or Admission form had no documentation of the date or time on September 9, 2015, for the Respiratory Treatment Service.

Review of MR11 revealed the Authorization for Treatment and/or Admission form had no documentation of the time on May 6, 2015, for the Respiratory Treatment Service.

Interview on September 30, 2015, at approximately 11:30 AM, with EMP7, confirmed the Authorization for Treatment and/or Admission forms for MR9, MR10, and MR11 were incomplete. EMP7 confirmed the Authorization for Treatment and/or Admission form was completed in registration.

Review of MR40 on October 1, 2015, at approximately 11:30 AM revealed the Authorization for Treatment and/or Admission form had no documentation of the time on August 4, 2015, for the Physical/Occupational/Speech Therapy Outpatient Service.

Interview on October 1, 2015, at approximately 11:30 AM, with EMP5, confirmed the Authorization for Treatment and/or Admission form for MR40 with no documentation of time on August 4, 2015 for Physical/Occupational/Speech Therapy Outpatient Service.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to complete a 30 day comprehensive care plan review for two of two swing bed patients (MR43 and MR50).

Findings include:

Review on October 1, 2015, of the facility's "Care Plan Requirements" policy, no review date, revealed "... Swing Bed Patient The nursing care plan is started upon admission. The facility must develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment. It is prepared by the Interdisciplinary Team that includes attending physician, RN who is responsible for the patient, other disciplines and staff as determined by the patient's needs. Also, if possible, the patient, family, and/or legal representative. The comprehensive care plan is periodically reviewed and revised by the team after each 30 day assessment and yearly, as resident status changes, condition changes, and/or progress is made. ..."

Review of MR43 on October 1, 2015, revealed this patient was admitted to the facility's swing bed program on September 12, 2014. Further review revealed the facility did not complete a comprehensive care plan review during October, November and December 2014, and January, February, March, April, May, and July 2015.

Interview with EMP2 on October 1, 2015, at approximately 3:00 PM confirmed MR43 was admitted to the facility's swing bed program on September 12, 2014, and the facility did not complete a comprehensive care plan review during October, November and December 2014, and January, February, March, April, May, and July 2015, as required by facility policy.

Review of MR50 on October 1, 2015, revealed this patient was admitted to the facility's swing bed program on July 24, 2013. Further review revealed the facility did not complete a comprehensive care plan review during September, November, and December 2014, and January, March, April, May, and July 2015.

Interview with EMP2 on October 1, 2015, at approximately 3:15 PM confirmed MR51 was admitted to the facility on July 24, 2013, and the facility did not complete a comprehensive care plan review during September, November, and December 2014, and January, March, April, May, and July 2015, as per facility policy.